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While working towards the completion of her Master’s of Public Health at the University of Waterloo, Barbara Fowler completed a 14-week practicum in Uganda with the Shanti Uganda Society. This non-governmental organization’s mission is to improve infant and maternal health and support women living with HIV/AIDS in the rural Luweero district of Uganda. Barbara’s main project was to develop a monitoring and evaluation strategy for Shanti’s birth house services. The birth house offers antenatal care, laboratory testing, labour and delivery and postnatal care.
Barbara's experience
In 2013, I secured an internship with the Shanti Uganda Society to complete the 14-week practicum component of the MPH program (University of Waterloo). Shanti Uganda’s mission is to improve infant and maternal health and support women living with HIV/AIDS in the rural Luweero district of Uganda. This non-governmental organization (NGO) has three main programs: the Birth House (maternal and infant care), a Teen Girls Health & Wellness Program, and a Women’s Income Generating group that employs women who are HIV positive.
Maternal and child health in Uganda
Maternal and child health conditions carry the highest total burden of disease in Uganda. The fertility rate is high. Women, on average, have seven children and Uganda has the highest rate of teenage pregnancy in Sub-Saharan Africa. These two factors predispose women to high-risk pregnancies and subsequently increase morbidity and mortality, particularly in rural settings where access to health care can be challenging. The maternal mortality ratio is 435 deaths per 100,000 live births. HIV prevalence among pregnant women presenting for antenatal care is estimated between 20-30%. Neonatal deaths contribute to 38% of all infants deaths.
The national average of Ugandans living below the poverty line is around 30%. Poverty was very apparent in the village setting where I lived and worked in. A direct relationship has been demonstrated between poverty and incidence of disease, as well as between poverty, access to health care and quality of care. The need is immense.
My role
My main project was to develop a monitoring and evaluation strategy for Shanti’s birth house services. The birth house offers antenatal care, laboratory testing, labour and delivery, and postnatal care. They also provide infant and child immunization, family planning, and treatment for malaria and other infections.
I achieved the following key deliverables through research and collaboration with Shanti staff
- An organizational logic model outlining program activities, target populations, and short, medium, and long-term outcomes.
- A Performance Measurement Framework (PMF) listing the main objectives, chosen indicators and rationale, and data collection tools.
- An indicator scorecard showing baseline measurements for each indicator and year-end targets.
- Revised and newly developed data collection tools for indicator measurement.
Utilizing my nursing background, I facilitated two Continuing Medical Education sessions for the nurse-midwife staff: post-partum depression, and essential newborn care and neonatal assessment. I also assisted in the delivery of a few of the infants born at the centre!
Knowledge and skill development
The project and experience allowed me to develop and strengthen my knowledge and skills in a number of important public health competencies. These included:
- Research, assessment and analysis:The project required considerable up-front research and assessment including data collection methods, relevant Millennium Development Goals, and Ugandan Ministry of Health indicators.
- Evaluation: The monitoring and evaluation strategy was developed utilizing the Results Based Management tools from the Canadian International Development Agency (CIDA) including their PMF.
- Partnerships, collaboration, and communication: Throughout the project, I had frequent formal and informal discussions with clinic staff to seek input, feedback, and clarification on program objectives, documentation, and measurement tools. A great deal of brainstorming was required to determine indicator targets and the strategies that would be implemented to reach the desired goals.
- Diversity and inclusiveness: The work challenged me to develop products that were appropriate, valuable, and effective for a client group that was largely unknown to me. I had to consider the local culture, language, and literacy in the creation of the plan, indicators, and data collection tools. These learnings were an eye-opening experience for me!
Reflections
Although I have worked in public health for twelve years, working and living in a developing country strengthened my appreciation of the significant impact that basic public health initiatives, such as clean water and sanitation, can have on community health and quality of life. The living and working conditions in the village could be challenging at times. Electricity was unreliable; power was available about 40% of the time. We would run to plug in our laptops and phones when the lights came on! Water was precious and required boiling. Food, although plentiful, lacked variety. Village life, however, demonstrated to me a number of important values; family and community, simplicity and resilience, hope and faith, acceptance and gratitude, ingenuity and achievement. The Ugandans I worked and lived with strived daily to improve their socioeconomic conditions and the negative consequences these conditions brought about. I formed valuable personal and professional relationships with the Shanti staff and volunteers and learned a great deal from them.
The placement allowed me the opportunity to practice in three areas of public health that I am passionate about – research, monitoring and evaluation, and international development. I discovered that I would like to pursue more focused opportunities in monitoring and evaluation work, either in regional or provincial public health arenas, or for an international NGO.
My time spent in Uganda was short. However, the experience was invaluable both personally and professionally. I wish to sincerely express my gratitude to the Sheela Basrur Centre for providing me with the funding that helped make this experience possible.
References
Government of Uganda, Ministry of Health. Uganda MOH Health Systems Strategic Plan to 2015; 2010. Available from: http://www.health.go.ug/docs/HSSP_III_2010.pdf
In the summer of 2013, Sanjana Mitra worked in western Kenya for Academic Model Providing Access to Healthcare (AMPATH). Sanjana’s placement was a component of her Master’s of Public Health Promotion program at the University of Toronto. AMPATH was originally created to respond to Kenya’s HIV/AIDS epidemic in the early 2000s, however, the organization has recently expanded its focus to include chronic disease care needs. AMPATH’s mission is to provide care, training and research to meet the health care needs of western Kenya. During her placement, Sanjana worked the Community Health Volunteer Incentive Project. The goal of this project was to provide a better understanding of the context in which AMPATH’s community health volunteers operate in western Kenya.
Sanjana's experience
I worked for an organization called AMPATH (Academic Model Providing Access to Healthcare. In the current context of western Kenya, AMPATH, a partnership between Moi University School of Medicine, Moi Teaching and Referral Hospital, and a consortium of North American medical universities, supports the Kenyan MOH in the provisioning of HIV and primary care. With the combined capacity of these academic medical centres, AMPATH’s mission is to provide care, training, and research to meet health care needs of western Kenya. The organization was originally created to respond to Kenya’s HIV/AIDS epidemic in the early 2000s by providing acute care services. However, more recently, in partnering with the Kenyan Ministry of Health, the organization has expanded from focusing exclusively on HIV/AIDS to address primary health care (PHC) and chronic disease care needs.
Many health service organizations in low and middle income countries incorporate community health volunteers (CHVs) into primary health care (PHC) to facilitate program implementation. While models vary, generally these CHVs have no or minimal formal education, and as such they are considered ‘non-skilled’ health workers. Besides initial allowances CHVs receive for participating in short trainings, they usually receive no or minimal additional payment for the tasks they perform. In the context of western Kenya, since 2011, AMPATH has been supporting approximately 1200 Government of Kenya CHVs in various PHC activities in the provinces of Nyaza, Rift Valley and Western. AMPATH supports PHC activities by providing CHVs an individual compensation of 2000 Kenyan Shillings (approximately $23 US dollars) per month, according to Kenyan government policy recommendations. However, as the future sustainability of CHV funding from AMPATH remains uncertain, AMPATH was looking to discontinue providing individual compensation to CHVs in fall 2013. Rather, the organization proposes sustaining financial incentives of CHVs by pooling individual incentives for investment in community-based organizations which can be used generate income though opening small businesses that aim to support CHVs financially in the long run.
I worked on the CHV Incentive Project. It aimed to better understand the context in which AMPATH’s CHVs operate in western Kenya, as well as explore the inequitable health worker roles that such programs may perpetuate, through the means of focus group discussions and interviews with CHVs and AMPATH staff they work closely with.
My role
What appealed to me the most about this opportunity was the project’s clearly defined structure and set of objectives. At the same time the project appeared to allow for independence in terms of protocol design and project coordination. It was also the opportunity to collaborate with the AMPATH staff.
During this placement, my official role was to act as the principal investigator and research coordinator of the project. Prior to leaving for Kenya, I spent most of my time on the project conducting a background literature review, creating the study’s research protocol, designing the research tools, and obtaining ethical approval from the University of Toronto and Moi University. While in Kenya, my day-to-day activities were to manage the logistics and facilitate data collection.
Knowledge and skill development
While my Master of Public Health Promotion degree has provided me with a theoretical background in health promotion, social determinants of health, and qualitative research, this practicum allowed me to apply these theoretical concepts to real world scenarios. Moreover, what really stood out about my experience with AMPATH compared to other global health placements I have experienced, was the level of integration of the organization within the existing health care system. I believe this contributed to my experience as a practicum student, providing me insight into how donor-funded organizations and programs function day-to-day. It also allowed me to come in contact with accomplished and driven Kenyans within my own team and from other academic institutions. Overall, this project was an ideal capstone project that has allowed me to bring together and use my skills from previous courses and experiences.
Reflections
This experience pushed my boundaries as a student and researcher. I learned that doing research within an existing large-scale organization can have its benefits and drawbacks. The major benefit of working within AMPATH was the network of individuals that was already established and functioning. This helped me to build relationships and find a position for myself within the organization. It also came in handy when dealing with the logistics of research such as making connections with key individuals, setting up meetings and organizing transportation necessary for data collection. However, some of the drawbacks of doing research within an organization such as AMPATH, particularly in a global health setting, are the inefficiencies and the rapidly changing realities of the organization on the ground.
After observing the lives of health professionals working full-time in Kenya, and according to my own experience, I saw how the injustices and inefficiencies in the health care system can quickly wear an individual down, particularly if one has few support systems. Nonetheless, I find great satisfaction in challenging global structures as a means to achieve health equity. Taking part in this internship made me realize that although I may not live abroad working on global health initiatives for extended periods, I will remain engaged in global health work in some capacity throughout my career.
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